If you have a Dental Benefits' Plan, do you need our help?

If YES, Please provide us some information.

Insurance Company Name

Insurance Phone

Policy Holder/ Subscriber

Name

Relationship To Patient

Policy Holder D.O.B.

Although we can be reached by U.S. Mail, Phone, and even through our websites private messaging system, on occasion, an E-mail might be the best way to communicate...
Please make a note of ours: Familydentalspa1@gmail.com

Your E-mail

To learn more about us, we would also like to Invite you to visit BrandonDentalSpa.com (our website). as well as to "Like Us" on Facebook; each of those sites will convey additional useful information for you to enjoy and be shared with loved ones who you might think would benefit from it.
We look forward to caring for your oral health and to continue earning your trust; the referrals of your friends and loved one will be your highest compliment and it will be very much appreciated AND acknowledged! Thank you!

Signature

Your insurance policy is a contract between you and your insurance company. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates. Payment is due at time of service. We accept cash and all major credits cards.
Any missed appointments without 24-hour notice, except in an emergency, will result in a charge of the patient. These charges are due and payable within 30 days.

Date

*

By clicking this circle I acknowledge I have read the above conditions of treatment and payment and agree to their content.

Do you have (or had) any Medical / Dental Condition, Disease, Disorder, or Problem not listed above?*

Yes

No

IF YES, please list here:

Other than for routine visits, have you been under the care of medical doctor - or hospitalized - during the past two years?*

Yes

No

IF YES, tell us when and for what reason?

Are you ALLERGIC to Latex, Penicillin, Aspirin Codeine, Erythromycin, Local Anesthesia or ANY OTHER drug OR medication not listed?*

Yes

No

IF YES, please list here:

Do you regularly take any Prescription or Over-the-counter Medications?*

Yes

No

IF YES, please list name and dosage:

Do you take or have you ever taken medication of Osteoporosis? [Such as Boniva, Zometa, Fosomax, Actonel, Reclast, Etc]*

Yes

No

Did your doctor ever say you had a cancer or a tumor? IF YES, please explain

Women, please, CLICK IF...*

You are taking birth control pills?

You are or could be pregnant?

How do you feel about the appearance of your teeth?

Is there anything that you wish you could change about your smile?

To the best of my knowledge, all of the proceeding answers and information provided are true and correct. If I ever have any changes in my health, I will inform Family Dental Spa of Brandon at the next appointment without fail.*

I agree

I disagree

By checking 'Agree' you agree the information provided is true and accurate to the best of your knowledge and you agree to inform this office in the event that information changes.

Dental History

what is the reason for your visit today?

Previous Dentist's Name

Last Hygiene Visit

Last X-Rays

How often do you have dental examination?*

How often do you brush your teeth?*

How often do floss?*

What other aids do you use? (Electric toothbrush, toothpick, etc..)*

Do you have any dental problems now?*

Yes

No

If yes, please describe

Are any of your teeth sensitive to

Click those apply:

Hot?

Cold?

Sweets?

Biting or Pressure?

Have you ever noticed any mouth odors or bad tastes?

Do you frequently get cold sores, blisters, or any lesions?

Do your gums bleed or hurt?

Have you or your parents experienced gum disease or tooth loss?

Have you noticed any loosen teeth or change in your bite?

Does food tend to become caught between your teeth?

Do you

Click those apply:

Clench or grind your teeth while wake or asleep?

Have tired jaws, especially in the morning?

Bite your lips or cheeks regularly?

Hold foreign objects with your teeth? (Pen,Pipe, Etc...)

Mouth breath while awake or asleep?

Snore?

Have you ever experienced

Click those apply:

Clicking or popping of the jaw?

Pain? (Joint,ear,side of face)

Difficulty opening or closing the mouth?

Frequently headaches, neck aches or shoulder aches?

Any pain or soreness in the muscles of your face or around the ears?

Have you ever had

click those apply

Orthodontic treatment?

Oral Surgery

Teeth removed?

If so, have they been replaced?

Fixed Bridge?

Removable Partial?

Complete Denture?

Implants?

Are you happy with the replacement?

Periodontal Treatment?

Gum Surgery?

Your teeth ground or bite adjusted?

A serious injury to the mouth or head?

Are you dissatisfied with appearance of your teeth?

Click those apply:

Are your teeth discolored?

Are your teeth crowded?

Would you like to charge the appearance of your teeth?

Do you feel anxiety about having a dental treatment?

Have you ever had an upsetting dental experience?

How do you overcome your anxiety?

If there is anything else about having a dental treatment that you like us to know, please describe.

Acknowledge of receipt of Notice of Privacy Practices prepared for (Print, please)*

A copy of their office's Notice of Privacy Practices has been made available to me; I have read it and I acknowledged its content. Signature of patient or parent/guradian*

Date*

Financial Policy, Options & Agreement:

Thank you for choosing us for your dental care, we appreciate the opportunity to serve you! We are committed to providing you - and those you love - with excellent dental care, and we realize a frank discussion of recommended treatment options, respective fees, and patient's financial capabilities & obligations prior to dental treatment helps relieve some of the anxiety associated with dental visits. Our fees are based on the quality of the products and materials we use and on our experience in performing each procedure.
On of our goals in NOT to allow expenses to be the factor that might prevent you from experiencing the benefits of optional dental health or a confident smile, therefore, in respect to payment options, billing and/or insurance coverage, and to confirm your understanding and agreement with our policies, please read the following:

For everyone's convenience... We offer several Payment Options; please check the box - or boxes - that you feel might apply or be of interest to you:*

2. A Discount will be extended to those who choose to Pre-Pay-in-Full by their first dental treatment's appointment, when dental work begins, this applies to fees and/or due amounts of $750 (Seven Hundred and Fifty) and above.

3. A number of Personalized Payment Plans are also available in-office or through "CareCredit";please asks us about them.

4. Assignment of Insurance Benefits will gladly be accepted under the following mutual understandings: a) that your insurance coverage carries a deductible and has a monetary annual limitation... b) that dental plans are not designed to provide 100% coverage of all types of necessary treatment, but that it is meant to assist you with the cost of your dental care... c) that we will do our best to give you an accurate estimation of the amount frequently covered by your insurance and the one to be paid by you, but that we will do so keeping in mind that, occasionally, insurance companies reserve their right to deny coverage or to pay less than expected or estimated... d) and that, since your dental benefits have been stipulated and contracted between you, your place of work, and your insurance company, once treatment is completed, all balances and/or costs not covered by your insurance are your responsibility.

Patients WITH insurance benefits, please not that unless a previously discussed financial arrangement is in place, the estimated patient's co-pay and deductible for the treatment rendered must be paid in full on the day of service. Please understand that you are ultimately responsible for all fees generated by your treatment.

Patients WITHOUT insurance benefits, please not that unless a previously discussed financial arrangement is in place, the fee for the treatment rendered must be paid in full on the day of services.

Our Billing System operates as follows:*

We will make every effort to help you return to - and maintain - a state of optimal oral health and, reasonably, payment is expected at the time of service; please know that we will be happy to help you design a payment plan that will work with your personal budget.

If all necessary treatment is well discussed, planned, and paced, it is very possible to keep account balances to Zero after treatment is completed. If a balance remains, you will receive a bill that indicates so.

For patients who have insurance; if the expected insurance payment is not received within sixty (600 days of completion of dental treatment, the remaining balance will be transferred to your account and billed to you for immediate payment.

We keep office billing to a minimum. All stagnant accounts with outstanding balances of 60 days will be turned over to an independent Collection Agency, and its fee and/or the additional fees incurred to collect payment of overdue accounts will be added to their balance.

I understand and agree to comply with this office's Financial Policy*

Agree

Disagree

By checking 'Agree' you agree the information provided is true and accurate to the best of your knowledge and you agree to inform this office in the event that information changes.

Informed consent

Patient Name:*

I hereby authorize my dentist, and whomever he/she may designate as his/her assistants and/or hygienists, to perform upon me those dental procedures which we have discussed, and I have accepted in the treatment plan. If any unforeseen condition arises in the course of these designated procedures calling, in their judgment, for procedures in addition to or different from those now contemplated, I further request and authorize whatever he deems advisable.

I consent to the treatment plan I have accepted after having been advised of alternate plans of treatment available.

I am informed to: post-treatment pressure and temperature sensitivity, pain or throbbing, pupal inflammation, fracturing of new restorations due to early biting pressures, tenderness of abutment teeth, tenderness of tissues under removable dentures, post-operative pain and throbbing, swelling and reinfection, fracturing of files or the crown portion of the tooth during and following root canal therapy, sensitivity of the teeth and gums during and following dental cleanings.

The most common of these complications in oral surgery include post-operative bleeding, swelling, or bruising, discomfort, stiff jaws, and loss or loosening of dental restorations. Other less common complications include, but are not limited to: infection, loss or injury to adjacent teeth and soft tissues, jaw fractures, sinus exposure and swallowing or aspiration of teeth and restorations, nerve disturbances (e.g. numbness in mouth and lip tissues), and small root fragments remaining in the jaw which might require extensive surgery for removal. These complications may be temporary or permanent.

I further consent to the administration of any drugs that may be deemed necessary in case, including, but not limited to: local anesthetics, antibiotics, and analgesics. I understand that there is a slight element of risk inherent in the administration of any drug of anesthesia. This risk includes, but is not limited to, the following complications: adverse drug response (e.g. allergic reactions), cardiac arrest, thrombophlebitis, (e.g. irritation and swelling of a vein), aspiration, pain, discoloration, and injury to blood vessels and nerves which may be caused by injections of any medications or drugs.

A more complete explanation of all complications is available to me upon request from my Doctor.

I am aware that, in spite of the possible complications and risks, my treatment is necessary and desired by me. I realize that the practice of dentistry is not an exact science, and I acknowledge that no guarantees have been made to me concerning the results of the procedures.